HomeMy WebLinkAbout1330A (199) WORKERS'COMPENSATION DECLARATION �qpp�,�CpT10N FOR PERMIT �
I hereby affirm tha�1 hove a tertifitote ot consent to self �
insure,or a certificate of Workers'Comp nsotion Insuronce, �bA�C r HEATING - VENiILAiING - A!R CONDITIONING Cp �
or a certifi f c.3800, C. ce-aie�aev.ioiai�
^Policy No �y �
� Certified copy is hereby furnished. � � COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed wi�h the county building inspec FOR APPLICANT TO FILL IN eUiIDiNG �
t� e me (PRINT OR TYPE ONLY) ADORESS %
Date pllwm LOCALITV
NO. TYPE OF APPLIANCE OR EOUIPMENT PEE
CERTIFICATE OF EXEMPTION FR M WORKERS' NEaRE57
COMPENSATION INSURANCE CRo55 si.
(This sxtion nwd not ba completed It fhe work Involwd.6y A050RPTION UNIT,BTU pisreicT No P ESSFD
tha parmif is For ono hundrod ddlars(:100)or bss.) �
AIR HANDLING UNIT,CFM
1 certify that in ihe performance of ihe work for which this
permit is issued,�shall not employ any person in any manner
so as to become subject fo Ihe Workers'Compensa�ion laws. 9OilER,BiU APVROVAtS DATE INSPECTOR'S SIGNATURE
Dafe APPliwnt COMPRESSOR.BTU ROUGH �
NOTICE TO APPLICANT: If, after making lhis Ceitificate of VENiILATION SVSTEM FINAI � �
Exemption, you shoutd become subject to the Workers' �-
Compensolion p�ovisions of the tabor Code,you must fonh- EVAPORA7IVE COOLER VALIDATION
with comply with such provisions or fhis permif shpll be '
daemed�evaked. FURNACE: FAU G
IICENSED CONTRACTORS�ECIARATION FLOOR a
I here6y affirm tha�I am licensed under provisions of Chapler 9 SUSPENDE� UNiT_
HEATER W �
(commencing with Section 7000)of Division 3 of the Busine5s
ond Rafessiona Code a d my I� ns is' fuli force and effett. �
License Nomber c Class r � -, � `�V�'�. (�j
r � a
Contra��f � e s • � s F', �
� e ��.- �- u
1 am exempt under Sec. j • w
Plan check fee _ y
6.8P.C.for this reosvn Dare PERMIT ISSUING PEE S � ,, _ 2
Signature TOTAL FEE
OWNER-BUILDER�ECLARATION PLAN CHECK APPLICANT
1 hereby affirm ihat I am exempt from the Coniractor's Licenze �
Law for the following reason(Section 7031.5, B�siness ond NAME
Professions Code):
❑ I, as owner of Ihe property, or my employees with A��RE55
woges as iheir sole compensation,wlll da Ihe work and g
the structure is not intended or oHered tor sole(Sectinn �ITY TEL NO. �
704d,6vsiness and Rofessions Code).
OWNER /`
❑ I,as owner of ihe property,am exclusively canfracting
wiih licensed contradors to construct the projed(Set- '�'A�� - �
� tion 7044,Business and Professians Code). AD�kE55
CONSTRUCTION LENDING AGENCY i.NO.
I hereby affirm ihat there is a cbnshuction(ending agency for
the parformance of the work for which this permi�is issued �ON7RACT �
(Sec.3097,Civ..C.). �
aooaEss
Lender's Name
� `_
Lender's Address (Q
TATE UC.
I certify thot 1 hove reod this applicalion and state that the IiCENSE NO. CtA$5
a6ove information is correc�.1 ogree la comply wiih all Co�nty
ordinances ond Stare laws relating ro building consrruction,
and hereby authorize rep.esenta�ives o4 tMs County ta enter
upon the ove-mentio ed op ty for inspectionpurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
.�
SignaNre o Apph<on1 or Agenl Do�e �
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